What is premenstrual dysphoric disorder (PMDD)?
Premenstrual dysphoric disorder (PMDD) is a severe, disabling form of premenstrual syndrome (PMS). In PMDD, the main symptoms are mood disorders such as depression, anxiety, tension, and persistent anger or irritability. These severe symptoms lead to problems with relationships and carrying out normal activities. Women with PMDD usually also have physical symptoms, such as headache, joint and muscle pain, lack of energy, bloating and breast tenderness.
According to the American Psychiatric Association, a woman must have at least five of the typical symptoms to be diagnosed with PMDD. The symptoms must occur during the two weeks before her period and go away when bleeding begins.
Many women experience premenstrual syndrome (PMS), and this may be thought of as the normal premenstrual experience. PMS symptoms are similar to those of PMDD. However, in PMDD the symptoms are severe enough to significantly impair, prevent or reduce the quality of social and personal relationships, home-life, work or study. PMDD affects between 3 and 5 per cent of women. Women with PMDD complain of irritability, anger, tension, marked depressed mood, and mood lability (crying spells for no reason, verbal outbursts, or tantrums ) to such a severity that quality of life is seriously compromised. In addition to these symptoms, some women complain of lethargy, sleep disturbance, limited concentration and a host of physical symptoms such as breast tenderness, headaches, joint and muscle pain, bloating and weight gain.
Although the exact cause of premenstrual dysphoric disorder is not known, several theories have been proposed. One theory states that women who experience PMDD may have abnormal reactions to normal hormone changes that occur with each menstrual cycle. This may include the fluctuation of estrogen and progesterone levels that normally occur with menstruation causing a serotonin deficiency, in some women (Serotonin is a substance found naturally in the brain and intestines that acts as a vessel-narrowing substance, or vasoconstrictor). Additional research is necessary.
The primary symptoms that distinguish premenstrual dysphoric disorder from other mood disorders (i.e., major depression) or menstrual conditions is the onset and duration of PMDD symptoms -- with symptoms appearing during the week or so before and disappearing within a few days after the onset of menses -- and the level by which these symptoms disrupt daily living tasks. (This diminished level of functioning is generally in great contrast with the same woman's interactions and abilities at other times during the month.) The symptoms of premenstrual dysphoric disorder may resemble other conditions or medical problems, such as a thyroid condition, depression, or an anxiety disorder. Consult a physician for diagnosis.
Treatment for premenstrual syndrome depends on the severity of the symptoms. For mild cases, treatment recommendations include diet modifications such as high carbohydrate meals and reducing salt, caffeine and alcohol, as well as a variety of methods for stress reduction and relaxation such as exercise, counselling and stress/behaviour management strategies.
For severe PMDD, treatment is more aggressive, often requiring pharmacological intervention in addition to nonpharmacological treatments. The selective serotonin reuptake inhibitor class of antidepressants are effective in the treatment of premenstrual dysphoric disorder. Fluoxetine (Prozac - Serafem) has been widely studied and found to be effective in reducing symptoms of tension, irritability and dysphoria. These results have been replicated with sertraline (Zoloft) and paroxetine (Paxil). Use of the SSRIs is positive as well in that side effects, such as nausea, diarrhea, headache, and insomnia, to name a few, are minimal and reportedly tolerable by the majority of women.
For some women, even more drastic measures must be taken to ameliorate the symptoms of PMDD. For these women, hormonal therapies are necessary that work by suppressing the menstrual cycle. Effective hormonal therapies include gonadotropin releasing hormone (GnRH) agonists, estradiol and danazol. With respect to the GnRH agonists, women may not be able to continue with this form of therapy in that side effects are similar to symptoms of menopause. This, then, can increase the occurrence or severity of osteoporosis. With estradiol treatment, women must be concurrently treated with progestogen to prevent endometrial hyperplasia. Danazol is effective, however, that has quite a severe adverse effect profile due to its androgenic and anti-estrogen properties. In addition, danazol treatment affects menstrual cycle length. Thus, the side effect profile of hormonal therapies makes them less tolerable in the treatment of PMDD.
For some women, the severity of symptoms increase over time and last until menopause (when menses ceases). For this reason, a woman may require treatment for an extended period of time, and may require several reevaluations to adjust medication dosages throughout the course of treatment.